Assessing brain aneurysms

ABSTRACT

This document provides methods and materials related to assessing brain conditions within mammals. For example, methods and materials that can be used to determine whether or not a mammal (e.g., a human) with a brain aneurysm is likely to experience brain aneurysm rupture are provided.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No. 11/912,540, having a filing date of May 27, 2008; which is a National Stage application under 35 U.S.C. §371 and claims benefit under 35 U.S.C. §119(a) of International Application No. PCT/US2005/014868 having an International Filing Date of Apr. 29, 2005. The disclosures of the prior applications are considered part of (and are incorporated by reference in) the disclosure of this application.

BACKGROUND

1. Technical Field

This document relates to methods and materials involved in assessing brain conditions. For example, this document relates to methods and materials involved in determining whether or not a brain aneurysm will rupture.

2. Background Information

About 10 to 15 million Americans are thought to suffer from a brain aneurysm with about 30,000 of these experiencing a brain aneurysm rupture (subarachnoid hemorrhage; SAH) annually. Unfortunately, about half of the SAH cases result in death or marked disability from the original hemorrhage or a major complication such as rebleeding or vasospasm. When confronting a patient with a brain aneurysm, a clinician recommends either treatment or continued monitoring. Treatment typically involves surgical clipping, endovascular coiling, or a variation thereof.

SUMMARY

This document involves methods and materials related to assessing brain conditions within mammals. For example, this document provides methods and materials that can be used to determine whether or not a mammal (e.g., a human) with a brain aneurysm is likely to experience rupture of the brain aneurysm. The discrepancy between the prevalence of brain aneurysms (as high as 5 percent or 10 to 15 million in the United States population alone) and the incidence of aneurysmal rupture (about 30,000 cases annually in the United States) suggests that some brain aneurysms are more prone to rupture than others (Schievink, N. Engl. J. Med., 336:28-40 (1997) and Inagawa et al., Surg. Neurol., 34:361-365 (1990)). Despite diagnostic and therapeutic advances, it is currently estimated that one-half of those afflicted with aneurysmal rupture will die or be markedly disabled from the original hemorrhage or a major complication such as rebleeding or vasospasm.

Typically, a mammal with a brain aneurysm can be assessed by determining whether or not the mammal contains a polymorphism in an eNOS gene. eNOS (endothelial nitric oxide synthase) polypeptides can be constitutively expressed and can catalyze the conversion of L-arginine into L-citrulline, thereby producing a rapidly diffusing signaling molecule, NO, as the major byproduct. The presence of a polymorphism in an eNOS gene can indicate that the mammal has high likelihood of experiencing brain aneurysm rupture. Determining whether or not a mammal has a high likelihood of experiencing brain aneurysm rupture by assessing the mammal's eNOS genotype as described herein can help clinicians determine the best course of treatment for that mammal. For example, a human brain aneurysm patient who normally might not receive surgical or endovascular treatment may be advised to undergo surgery or endovascular treatment if it is determined that that patient has an allele having at least one polymorphism in an eNOS gene.

In general, this document features a method for assessing a human having a brain aneurysm. The method includes determining whether or not the human contains two or more polymorphisms in SEQ ID NO:1, wherein the presence of the two or more polymorphisms indicates that the brain aneurysm is prone to rupture. The brain aneurysm can be between 2 and 10 mm in diameter. The brain aneurysm can be present in an anterior or posterior communicating artery of the human. The human can be heterozygous for the two or more polymorphisms. The human can be homozygous for the two or more polymorphisms. The method can include determining whether or not the human contains three or more polymorphisms in SEQ ID NO:1. The polymorphisms can be selected from the group consisting of 27 VNTR, T-786C SNP, and G894T SNP.

In another embodiment, this document features a method for determining whether or not to treat a brain aneurysm in a human. The method includes determining whether or not the human contains two or more polymorphisms in SEQ ID NO:1, wherein the presence of the two or more polymorphisms indicates that the brain aneurysm should be treated. The brain aneurysm can be between 2 and 10 mm in diameter. The brain aneurysm can be present in an anterior or posterior communicating artery of the human. The human can be heterozygous for the two or more polymorphisms. The human can be homozygous for the two or more polymorphisms. The method can include determining whether or not the human contains three or more polymorphisms in SEQ ID NO:1. The polymorphisms can be selected from the group consisting of 27 VNTR, T-786C SNP, and G894T SNP. The method can include determining the size of the brain aneurysm. The method can include determining the location of the brain aneurysm.

In another embodiment, this document features a method for determining whether or not to treat a brain aneurysm in a human. The method includes (a) determining whether or not the human contains two or more polymorphisms in SEQ ID NO:1, and (b) determining whether or not the brain aneurysm has a size between 2 and 10 mm in diameter or determining whether or not the brain aneurysm has a location in an anterior or posterior communicating artery of the human, wherein the presence of the two or more polymorphisms in the human and the presence of the size or the location indicates that the brain aneurysm should be treated. The method can include determining whether or not the human is homozygous for the two or more polymorphisms. The human can be heterozygous for the two or more polymorphisms. The human can be homozygous for the two or more polymorphisms. The method can include determining whether or not the human contains three or more polymorphisms in SEQ ID NO:1. The polymorphisms can be selected from the group consisting of 27 VNTR, T-786C SNP, and G894T SNP. The method can include determining whether or not the brain aneurysm has a size between 2 and 10 mm in diameter and determining whether or not the brain aneurysm has a location in an anterior or posterior communicating artery of the human, wherein the presence of the two or more polymorphisms in the human and the presence of the size and the location indicates that the brain aneurysm should be treated.

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention pertains. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described below. All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and not intended to be limiting. Other features and advantages of the invention will be apparent from the following detailed description, and from the claims.

DESCRIPTION OF DRAWINGS

FIG. 1 is a diagram depicting three eNOS gene polymorphisms along with their respective locations in the eNOS gene. For each polymorphism, the putative abnormal allele is indicated by an asterisk. Abbreviations: 4a=four 27-base pair tandem repeats; 4b=five 27-base pair tandem repeats; C=cytosine; G==guanine; kbp=kilobase-pairs; NO=nitric oxide; SNP=single nucleotide polymorphism; T=thymine; TIS=transcription initiation sequence; VNTR=variable number tandem repeat.

FIG. 2 is a nucleic acid sequence listing of a human eNOS gene (SEQ ID NO:1).

FIG. 3 is an amino acid sequence listing of a human eNOS polypeptide (SEQ ID NO:2).

FIG. 4 is a listing of the human eNOS gene set forth in FIG. 1 labeling exons, untranslated regions (UTR), and polymorphisms. The nucleic acid sequence is as set forth in SEQ ID NO:1, while the amino acid sequence is as set forth in SEQ ID NO:2.

DETAILED DESCRIPTION

This document provides methods and materials related to assessing brain conditions within mammals. For example, this document provides methods and materials that can be used to determine whether or not a mammal (e.g., a human) with a brain aneurysm is likely to experience brain aneurysm rupture. As described herein, a mammal having a polymorphism in an eNOS gene can have a higher likelihood of experiencing brain aneurysm rupture than a mammal not having a polymorphism in an eNOS gene. The term “eNOS gene” as used herein includes the exons that encode an eNOS polypeptide, any introns located between such exons, the promoter region, the sequences up to 3 kilobases (e.g., 0.5, 1, 1.5, 2, 2.5, or 3 kilobases) 5′ of the transcriptional start site, and the sequences up to 3 kilobases (e.g., 0.5, 1, 1.5, 2, 2.5, or 3 kilobases) 3′ of the stop codon. For example, the sequence set forth in SEQ ID NO:1 (FIG. 2) can be an eNOS gene in the case of a human. See, also, GenBank® Accession No. AF519768.

Any mammal having a brain aneurysm can be assessed to determine whether or not the mammal has a high likelihood of experiencing brain aneurysm rupture. For example, dogs, cats, horses, pigs, cows, sheep, monkeys, and humans can be assessed for the presence or absence of a polymorphism in an eNOS gene. The nucleic acid sequence for a particular mammalian species can be found in GenBank® or can be determined using common molecular biology techniques. In some cases, several eNOS genes can be sequenced from multiple members of the same species to determine a common wild-type sequence to which polymorphic sequences can be compared. In the case of humans, the sequence set forth in SEQ ID NO:1 can be used as a wild-type sequence to which polymorphic sequences are compared. For example, any sequence deviation from the sequence set forth in SEQ ID NO:1 found in a human can be considered a polymorphism. In some cases, the first or consensus nucleic acid sequence deposited in GenBank® for a particular mammalian species can be used as a wild-type sequence to which polymorphic sequences are compared for that species.

A mammal can be assessed to determine whether or not that mammal contains any type of polymorphism in an eNOS gene including, without limitation, insertions, deletions, substitutions, repeats, inverted repeats, and combinations thereof. In some embodiments, a human can be assessed to determine whether or not the human contains the intron-4 27-base pair variable-number-tandem-repeat polymorphism, 27 VNTR; the promoter SNP, T-786C SNP; or the exon-7 SNP, G894T SNP (FIG. 1). Additional examples of polymorphisms that can be used in the case of humans include, without limitation, any of the polymorphisms provided in FIG. 3 or set forth in the Single Nucleotide Polymorphism database of GenBank® with any of the following reference SNP identification numbers: rs3918234; rs1799983; rs3918166; rs3918232; rs3918201; rs3918155; rs1800779; rs3918158; rs3918157; rs2243310; rs3918163; rs2070744; rs3918225; rs10952298; rs3918226; rs3918159; rs3918160; rs2243311; rs3918162; rs3918156; rs3918161; rs1800783; rs2853792; rs3918170; rs3918192; rs1008140; rs1800782; rs3918187; rs7830; rs2853795; rs3918205; rs3730002; rs3918202; rs3918178; rs753482; rs3918193; rs3918204; rs3918237; rs3918164; rs1800781; rs1800780; rs3918177; rs3918231; rs3918194; rs3730305; rs743507; rs3918184; rs3730009; rs867225; rs3918228; rs3918182; rs3918195; rs3918207; rs1007311; rs3918235; rs3918230; rs3918185; rs3918169; rs3730001; rs2853796; rs3834873; rs3918227; rs3918175; rs3918165; rs3793341; rs3918209; rs3918176; rs3918196; rs1541861; rs3730003; rs3918188; rs3793342; rs2566511; rs3918208; rs3918174; rs3918167; rs2256314; rs3918197; rs1065300; rs3918229; rs3918203; rs1808593; rs3918198; rs3918180; rs891511; rs3918236; rs891512; rs3918189; rs3729625; rs3918210; rs3918173; rs3918168; rs743506; rs3918181; rs3918190; rs3918199; rs3918200; rs3918191; rs3918186; rs7792133; rs6947833; rs2566516; rs2566519; rs11371169; rs3730306; rs2566508; rs3730007; rs13305985; rs3918179; rs2853791; rs13420; rs1799984; rs13310854; rs10539416; rs2566506; rs2566517; rs6969597; rs12937; rs2853797; rs2853794; rs2566510; rs10539415; rs13311313; rs13310763; rs2566507; rs10595051; rs2853793; rs3730012; rs2566513; rs11974098; rs3918183; rs13305984; rs2566512; rs13311166; rs13310774; rs3730006; rs1799985; rs7776461; rs2853798; rs2566518; rs13305982; rs3730010; rs2853800; rs2566515; rs2566509; rs10255980; rs4725985; rs3828997; rs933163; rs3134740; rs11771443; or rs10531586.

A mammal can be assessed to determine whether or not that mammal contains a single polymorphism or multiple polymorphisms in an eNOS gene. For example, a mammal can be assessed to determine whether or not that mammal contains one, two, three, four, five, six, seven, eight, nine, ten, or more polymorphisms in an eNOS gene. In some embodiments, a human can be assessed to determine whether or not the human contains any combination of the polymorphisms provided herein such as (1) 27 VNTR, T-786C SNP, and G894T SNP; (2) 27 VNTR and T-786C SNP; (3) 27 VNTR and G894T SNP; (4) T-786C SNP and G894T SNP; (5) 27 VNTR and any of the polymorphisms provided in FIG. 3; (6) T-786C SNP and any of the polymorphisms provided in FIG. 3; or (7) G894T SNP and any of the polymorphisms provided in FIG. 3. The polymorphisms in an eNOS gene can be present on the same allele or on different alleles. For example, a human having two polymorphisms in an eNOS gene such as the 27 VNTR and T-786C SNP can have one allele containing both the 27 VNTR and T-786C SNP, or can have one allele containing the 27 VNTR and the other allele containing the T-786C SNP. In addition, a mammal can be heterozygous or homozygous for a particular polymorphism. For example, one allele can contain the T-786C SNP, or both alleles can contain the T-786C SNP.

Since a mammal having one or more polymorphisms (e.g., one, two, three, four, five, six, seven eight, nine, ten, or more polymorphisms) in an eNOS gene can have a higher likelihood of experiencing brain aneurysm rupture than a mammal not having those polymorphisms in an eNOS gene, the methods and materials provided herein can be used to determine whether or not to treat a brain aneurysm in a mammal. In some cases, the size of a brain aneurysm, the location of a brain aneurysm, or both can be used in addition to assessing the mammal for the presence or absence of polymorphisms in an eNOS gene to determine whether or not to treat the brain aneurysm. Typically, a clinician can recommend treating a brain aneurysm surgically when any one, two, or three of the following are determined: (1) the brain aneurysm's size is between 1 and 35 mm (e.g., between 1 and 20 mm, between 1 and 15 mm, between 2 and 10 mm, between 2 and 8 mm, or between 3 and 6 mm) in diameter, (2) the brain aneurysm's location is in the human's intracranial circulation (e.g., in an anterior or posterior communicating artery), and (3) the mammal contains one or more polymorphisms in an eNOS gene.

Any common diagnostic technique can be used to identify a mammal having a brain aneurysm. For example, diagnostic techniques such as cerebral angiography, magnetic resonance angiography (MRA), or computerized tomographic angiography (CTA) can be used to identify the presence, size, and location of a brain aneurysm within a mammal (e.g., a human). In addition, any method can be used to determine whether or not a mammal contains a polymorphism in an eNOS gene. For example, polymorphisms in an eNOS gene can be detected by sequencing or by performing allele-specific hybridization, allele-specific restriction digests, mutation specific polymerase chain reactions (MSPCR), single-stranded conformational polymorphism (SSCP) detection (Schafer et al., Nat. Biotechnol., 15:33-39 (1995)), denaturing high performance liquid chromatography (DHPLC, Underhill et al., Genome Res., 7:996-1005 (1997)), infrared matrix-assisted laser desorption/ionization (IR-MALDI) mass spectrometry (WO 99/57318), or combinations of such methods.

Genomic DNA or mRNA can be used in the analysis of polymorphisms. Genomic DNA is typically extracted from a biological sample such as blood, but can be extracted from other biological samples including tissue samples. Routine methods can be used to extract genomic DNA from a blood or tissue sample, including, for example, phenol extraction. Alternatively, genomic DNA can be extracted with kits such as the QIAamp® Tissue Kit (Qiagen, Chatsworth, Calif.), Wizard® Genomic DNA purification kit (Promega), and the A.S.A.P.™ Genomic DNA isolation kit (Boehringer Mannheim, Indianapolis, Ind.). In some cases, an amplification step can be performed prior to detecting a polymorphism. For example, nucleic acid from an eNOS gene can be amplified and then directly sequenced. Dye primer sequencing can be used to increase the accuracy of detecting heterozygous samples.

Hybridization also can be used to detect polymorphisms. See, for example, Stoneking et al., Am. J. Hum. Genet., 48:370-382 (1991) and Prince et al., Genome Res., 11:152-162 (2001). In practice, samples of DNA or RNA from one or more individuals can be amplified using pairs of primers, and the resulting amplification products can be immobilized on a substrate (e.g., in discrete regions). Hybridization conditions can be selected such that an oligonucleotide binds to a sequence of interest, e.g., a polymorphic nucleic acid sequence. Such hybridizations typically are performed under high stringency as some polymorphic nucleic acid sequences include only a single nucleotide difference. High stringency conditions can include the use of low ionic strength solutions and high temperatures for washing. For example, nucleic acid molecules can be hybridized at 42° C. in 2×SSC (0.3M NaCl/0.03 M sodium citrate) with 0.1% sodium dodecyl sulfate (SDS) and washed in 0.1×SSC (0.015M NaCl/0.0015 M sodium citrate), 0.1% SDS at 65° C. Hybridization conditions can be adjusted to account for unique features of the nucleic acid molecule, including length and sequence composition. Probes can be labeled (e.g., fluorescently or with biotinylation) to facilitate detection.

For polymorphic nucleic acid sequences that introduce a restriction site, restriction digest(s) with the appropriate restriction enzyme(s) can differentiate wild-type and polymorphic sequences. For polymorphic sequences that do not alter a common restriction site, mutagenic primers can be designed that introduce a restriction site when the polymorphic sequence is present or when a wild-type sequence is present. A portion of an eNOS gene can be amplified using the mutagenic primer and a wild-type primer, followed by digest with the appropriate restriction endonuclease.

Certain polymorphic sequences, such as insertions or deletions of one or more nucleotides, can change the size of a DNA fragment encompassing a polymorphism. The insertion or deletion of nucleotides can be assessed by amplifying the region encompassing the polymorphic sequence and determining the size of the amplified products in comparison with size standards. For example, a region of an eNOS gene that encodes an eNOS polypeptide or regulates expression of an eNOS polypeptide can be amplified using a primer set from either side of a polymorphic sequence. One of the primers is typically labeled, for example, with a fluorescent moiety, to facilitate sizing. The amplified products can be electrophoresed through acrylamide gels with a set of size standards that are labeled with a fluorescent moiety that differs from the primer.

In some embodiments, PCR conditions and primers can be developed that amplify a product only when a particular polymorphic sequence is present or only when the polymorphic sequence is not present (MSPCR or allele-specific PCR). For example, patient DNA and a control can be amplified separately using either a wild-type primer or a primer specific for a polymorphic sequence. Each set of reactions can then be examined for the presence of amplification products using standard methods to visualize the DNA. For example, the reactions can be electrophoresed through an agarose gel, and the DNA visualized by staining with ethidium bromide or other DNA intercalating dye. In nucleic acid samples from heterozygous mammals, reaction products can be detected with each set of primers. Mammalian samples containing solely the wild-type allele would have amplification products only in the reaction using the wild-type primer. Similarly, mammalian samples containing solely the polymorphic allele can have amplification products only in the reaction using the primer containing the polymorphic sequence. Allele-specific PCR also can be performed using allele-specific primers that introduce priming sites for two universal energy-transfer-labeled primers (e.g., one primer labeled with a green dye such as fluoroscein and one primer labeled with a red dye such as sulforhodamine).

Amplification products can be analyzed for green and red fluorescence in a plate reader. See, Myakishev et al., Genome, 11(1):163-169 (2001).

Mismatch cleavage methods also can be used to detect differing sequences by PCR amplification, followed by hybridization with a wild-type sequence and cleavage at points of mismatch. Chemical reagents, such as carbodiimide or hydroxylamine and osmium tetroxide can be used to modify mismatched nucleotides to facilitate cleavage.

The invention will be further described in the following examples, which do not limit the scope of the invention described in the claims.

EXAMPLES Example 1 The Presence of Tandem eNOS Gene Polymorphisms Identifies Brain Aneurysms Prone to Rupture

The following experiments were performed to determine whether polymorphisms in eNOS can be used to identify brain aneurysms prone to rupture.

Study Participants

A prospective case-control study involved 107 human subjects each of whom gave informed consent for participation. The control group consisted of 49 people consecutively presenting to the Mayo Clinic with a diagnosis of unruptured intracranial saccular aneurysm. The case group was comprised of 58 people consecutively admitted to the Mayo Clinic diagnosed with aneurysmal subarachnoid hemorrhage (SAH) based on history and radiological findings, including both admission head computerized tomography scan and 4-vessel cerebral angiography.

Genetic Analysis

Three particular eNOS polymorphisms were analyzed (FIG. 1). A single 20 mL sample of peripheral venous blood was obtained from all participants for subsequent DNA extraction and genetic analysis. Genomic DNA was extracted from peripheral blood lymphocytes using QIAamp® DNA Blood Minikit (Qiagen, Germantown, Md.). SNPs were genotyped using Nanochip™ active electronic arrays (Nanogen, San Diego, Calif.) as described elsewhere (Sohni et al., Clin. Chem., 47:1922-1924 (2002)). Oligo 6.61 software was used to design polymerase chain reaction (PCR) primers (IDT, Coralville, Iowa) based on GenBank sequences. PCR mixtures consisted of 25 μL AmpliTaq Gold Master Mix (Applied Biosystems, Foster City, Calif.), 1 μM primers, 20 ng DNA template and water to 50 μL. All oligonucleotides were synthesized by IDT. Primer sequences were 5′-biotin-GCATGCACTCTGGCCTGAAGT-3′ (forward; SEQ ID NO:3) and 5′-CAGGAAGCTGCCTTCCAGTGC-3′ (reverse; SEQ ID NO:4) for eNOS T-786C SNP, and 5′-biotin-CTGGAGATGAAGGCAGGAGAC-3′ (forward; SEQ ID NO:5) and 5′-CTCCATCCCACCCAGTCAATC (reverse; SEQ ID NO:6) for eNOS G894T SNP. Thermal cycling conditions for each were 95° C. for 10 minutes, 30 cycles of 94° C. for 30 seconds, 58° C. for 30 seconds, and 72° C. for 45 seconds, and final extension at 72° C. for 7 minutes. For eNOS T-786C SNP, reporter probes were 5′-Cy3-AGGGTCAGCCA-3′ (SEQ ID NO:7) and 5′-Cy5-GGGTCAGCCG-3′ (SEQ ID NO:8) with stabilizer oligonucleotide 5′-GCCAGGGAAGAGCTTGATGCCCTGGTGGGAGC-3′ (SEQ ID NO:9). For eNOS G894T SNP, reporter probes were 5′-Cy3-GTTCTGGGGGC-3′ (SEQ ID NO:10) and 5′-Cy5-AGTTCTGGGGGA-3′ (SEQ ID NO:11) with stabilizer oligonucleotide 5′-TCATCTGGGGCCTGCAGCAGCAGGGGCAGCA-3′ (SEQ ID NO:12). Known heterozygotes, verified by dye-terminator sequencing performed on ABI 377 DNA sequencers in both forward and reverse directions, were used as controls to normalize hybridization efficiency between dye-labeled reporters. PCR conditions and methods for analyzing the eNOS 27 VNTR polymorphism are detailed elsewhere (Sohni et al., Clin. Biochem., 36:35-39 (2003)). PCR products were analyzed using DNA 500 LabChip® kit on Agilent 2100 Bioanalyzer (Agilent Technologies, Wilmington, Del.) following the manufacturer's instructions. DNA fragment sizes were determined for each sample from the calibration curve in conjunction with markers and sizing ladder. Genotypes were designated based on fragment sizes obtained at the end of the run. For each polymorphism, amplicons were randomly sequenced to determine concordance with microarray genotyping as described herein.

Data Analysis

In order to evaluate the association between the demographic and genetic markers of interest and aneurysmal disease, comparisons were made between cases and controls. Demographics are presented as mean±standard deviation (SD) for continuous variables and percentage of column totals for categorical variables. Univariate associations between demographic variables and disease were assessed using two-sample t-test for continuous variables and Pearson's chi-square or Fisher's exact test (when sample sizes were limited) for categorical variables. Before any statistical analysis of disease-marker associations, allele frequency distribution at each polymorphism locus was tested against Hardy-Weinberg equilibrium (HWE) under Mendelian bi-allelic expectation using the chi-square test. Univariate associations of allele (which treats each chromosome as a unit) and genotype (which treats a person as a unit) with disease were evaluated using contingency table methods in SAS-v8.2. Allele associations were assessed using Pearson's chi-square or Fisher's exact test (when sample sizes were limited) and genotype associations were assessed using the Cochran-Armitage trend test. The multiple polymorphism marker-disease association with haplotype was evaluated using Haplo.score which accounts for ambiguous linkage phase (Lake et al., Hum. Hexed., 55:56-65 (2002) and Schaid et al., Am. J. Hum. Genet., 70:425-434 (2002)). Haplotype odds ratios (OR) and 95% confidence intervals (CI) were calculated using Haplo.glm. The haplotype comprised of 3 wild-type alleles (4b-T-G) was used as the comparison to calculate the haplotype specific OR and CI. Linkage disequilibrium was assessed using the Graphical Overview of Linkage Disequilibrium (GOLD) software package (Abecasis and Cookson, Bioinformatics, 16:182-3 (2002) and Ardlie et al., Nat. Rev. Genet., 3:299-309 (2002)). All tests were two-sided and P-values <0.05 were considered statistically significant.

Clinical Data

When comparing aneurysm cases and controls, there was no significant difference in mean age, gender or race, history of cardiovascular diseases or smoking, or family history of brain aneurysms or SAH (Table 1). Although multiplicity of aneurysms was similar between the two groups, cases presented with significantly smaller aneurysms compared with controls (7.5±4.7 mm vs. 9.6±5.8 mm; P=0.037). The distribution and treatment of aneurysms also differed significantly between the two groups (P<0.001; Table 1).

TABLE 1 Demographic and clinical data for people with unruptured (controls) compared with ruptured (subarachnoid hemorrhage; SAH; cases) brain aneurysms. Variable Controls (n = 49) Cases (n = 58) P-value Age 57.1 ± 11.5 53.2 ± 12.7 0.10 Female gender 36 (73%) 39 (67%) 0.48 Caucasian race 49 (100%) 58 (100%) N/A Cardiovascular comorbidities: Diabetes mellitus 4 (8%) 4 (7%) 0.80 Hypertension 25 (51%) 24 (41%) 0.32 Coronary artery disease 4 (8%) 7 (12%) 0.51 Ischemic stroke 10 (20%) 5 (9%) 0.08 History of smoking 28 (57%) 41 (71%) 0.14 Family history of brain 8 (16%) 4 (7%) 0.12 aneurysm or SAH Aneurysm size (mm) 9.6 + 5.8 7.5 + 4.7 0.037 Multiple aneurysms 16 (33%) 15 (26%) 0.44 Aneurysm location: <0.001 Anterior communicating 3 (6%) 16 (28%) artery Anterior cerebral artery 2 (4%) 5 (9%) Middle cerebral artery 17 (35%) 5 (9%) Internal carotid artery 17 (34%) 7 (12%) Posterior 1 (2%) 13 (22%) communicating artery Posterior cerebral artery 1 (2%) 2 (3%) Basilar artery 6 (12%) 7 (12%) Vertebral artery 2 (4%) 3 (5%) Aneurysm treatment: <0.001 Clip 22 (45%) 24 (41%) Coil 10 (20%) 30 (52%) Coil then clip 0 1 (2%) None 17 (35%) 3 (5%)

Genetic Data

Hardy-Weinberg Equilibrium (HWE): Among controls, the genotype frequencies for eNOS 27 VNTR (P=1.0) and eNOS G894T SNP (P=0.06) were in agreement with those predicted by the HWE. The genotype frequencies for eNOS T-786C SNP (P=0.03) were not in agreement with those predicted by the HWE. Thus, the Cochran-Armitage trend test (which is unaffected by departure from HWE) was implemented and revealed consistent results. For the eNOS T-786C SNP, the departure from HWE was due to a homozygote favoring which was shown to have minimal effect on haplotype estimation (Lake et al., Hum. Hered., 55:56-65 (2002)). Further, to exclude the possibility of genotyping error, thirty-seven T-786C SNP amplicons were randomly sequenced, and the results were found to be fully concordant with microarray genotyping.

Allele and Genotype Frequencies: For each of the three polymorphisms, significant differences in allele and genotype frequency were found between cases and controls with the variant alleles and their corresponding genotypes being present two-to-four times more often among cases (Table 2). Linkage disequilibrium analysis (Ardlie et al., Nat. Rev. Genet., 3:299-309 (2002)) was carried out using both D′ and R2 to detect pair-wise linkage disequilibrium among the three polymorphisms. No significant linkage disequilibrium was detected.

TABLE 2 Allele and genotype data for people with unruptured (controls) compared with ruptured (cases) brain aneurysms. Controls (n = 49) Cases (n = 58) Locus N (%) N (%) P-value Allele frequency: eNOS 27 VNTR 0.003 Allele 4a^(†) 10 (10) 30 (26) Allele 4b 88 (90) 86 (74) eNOS T-786C SNP 0.003 Allele C^(†) 21 (21) 47 (41) Allele T 77 (79) 69 (59) eNOS G894T SNP <0.001 Allele T^(†) 10 (10) 38 (33) Allele G 88 (90) 78 (67) Genotype frequency: eNOS 27 VNTR 0.006 4a/4a 0 1 (2) 4a/4b 10 (20) 28 (48) 4b/4b 39 (80) 29 (50) eNOS T-786C SNP <0.001 C/C 5 (10) 6 (10) C/T 11 (22) 35 (60) T/T 33 (67) 17 (29) eNOS G894T SNP <0.001 T/T 2 (4) 6 (10) T/G 6 (12) 26 (45) G/G 41 (84) 26 (45) ^(†)Variant allele

Haplotype Frequencies

A haplotype analysis consisting of 20,000 simulations was implemented to assess the multiple polymorphism marker-disease associations. The observed results were summarized using the simulated P-value, control and case haplotype frequencies, OR, and the 95% CI for each of the eight possible haplotypes (Table 3). Haplotype 4a-C-T, which includes the variant allele for all 3 polymorphisms, was found in 8.4% of cases and 2.3% of controls (simulated P=0.0038), and subjects having this haplotype had an 11.4-fold (1.7-75.9 95% CI) increased odds of being a case. The second identified risk haplotype 4a-C-G, which includes the variant allele for eNOS 27 VNTR and eNOS T-786C SNP, was found in 14.1% of cases and 3.1% of controls (simulated P=0.0196), and subjects having this haplotype had an 8.6-fold (1.8-41.3 95% CI) increased odds of being a case. The third risk haplotype 4b-C-T, which includes the variant allele for eNOS T-786C SNP and eNOS G894T SNP, was found in 13.2% of cases and 2.7% of controls (simulated P=0.0077), and subjects having this haplotype had a 9.3-fold (1.7-49.9 95% CI) increased odds of being a case.

TABLE 3 Haplotype data for people with unruptured (controls) compared with ruptured (cases) brain aneurysms. eNOS eNOS eNOS Control Odds ratio 27 T-786C G894T Simulated Haplotype Case Haplotype (95% confidence VNTR SNP SNP P-value Frequency Frequency interval) 4a C T 0.004 0.02 0.08 11.4 (1.7-75.9) 4a T T NA 0.01 <0.001 NA 4a C G 0.02 0.03 0.14  8.6 (1.8-41.3) 4a T G 0.87 0.04 0.03  2.2 (0.4-13.1) 4b C T 0.008 0.03 0.13  9.3 (1.7-49.9) 4b T T 0.07 0.04 0.11  4.4 (0.9-22.4) 4b C G 0.1 0.13 0.05  0.5 (0.1-1.8) 4b T G <0.001 0.70 0.45  1.0 (NA)

The results provided herein demonstrate that the presence of two or more variant eNOS alleles in a brain aneurysm patient is associated with an approximately 10-fold increased odds of presenting with aneurysmal rupture. The results also demonstrate that there are two distinct subpopulations of intracranial aneurysms, distinguishable by anatomical and genetic features, with one being more prone to rupture than the other.

The precise molecular effects of eNOS polymorphisms have not been elucidated, although there is biochemical evidence for decreased eNOS gene promoter activation associated with the T-786C SNP variant and reduced eNOS polypeptide expression and enzymatic activity associated both with eNOS 27 VNTR and T-786C polymorphism variants (Nakayama et al., Circulation, 99:2864-2870 (1999) and Song et al., Clin. Chem., 49:847-852 (2003)). It is certainly conceivable that such variants may contribute towards aneurysm pathobiology and cerebral vasospasm through increased local oxidative stress leading to vessel wall damage, predilection towards development of atherogenic intimal hyperplasia and systemic hypertension, the presence of aberrant vascular smooth muscle proliferation, and increased platelet aggregation and pro-inflammatory monocyte adhesion, all of which are associated with NO signaling dysfunction. Such mechanisms may also account for the impaired vasorelaxation and heightened vascular wall inflammation characteristic of post-SAH vasospasm.

The results provided herein demonstrate the existence of rupture-prone versus rupture-resistant subpopulations of brain aneurysms. Despite the similarities of demographic and clinical characteristics between the two groups, the genetic differences between the two groups were striking Polymorphic variant alleles and their corresponding genotypes were found to be between two-to-four times more frequent among cases compared with controls, and the haplotype analysis indicated that the presence of two or more (e.g., three) variant alleles was associated with an 8.6 to 11.4 increased odds of being a case (i.e., presenting with a ruptured brain aneurysm). Taken together, the anatomical and genetic data suggest that there are distinct differences between ruptured compared with unruptured aneurysms: the former are smaller, have a greater predilection for the anterior and posterior communicating arteries, and have a tendency to occur more commonly in persons with two or more (e.g., three) variant eNOS polymorphic alleles.

Clinical Implication of these Results

Among the estimated 5-15% of aneurysm-harboring individuals with a relatively strong family history of brain aneurysms or with a heritable connective tissue disorder (such as Ehlers-Danlos, Marfan, or autosomal dominant polycystic kidney disease), noninvasive radiological screening for brain aneurysms is accepted as being worthwhile. For the remaining majority of people at this time referred to as having “sporadic” unruptured brain aneurysms; however, there is currently no adequate screening tool. To identify such individuals via population-wide serial radiological screening seems largely impractical, and there is no “aneurysm gene” yet identified. An important aspect of brain aneurysm management at this time can be how to counsel a patient with a newly diagnosed brain aneurysm (e.g., observation versus treatment). ISUIA has suggested certain aneurysms are more prone to rupture; however, counsel based on ISUIA data alone may not cover the gamut of rupture-prone aneurysms. As described herein, a person diagnosed incidentally or otherwise with an unruptured intracranial aneurysm (especially one located in a higher-risk cerebrovascular territory) and in whom two or more (e.g., three) variant eNOS polymorphic alleles are found, for example, by gene microarray technology, can be counseled towards earlier treatment rather than observation. In addition, a rapid and cost-effective eNOS polymorphism screening tool can be used by clinicians as a genetic aid to predicting rupture risks in patients presenting with unruptured intracranial aneurysms.

Other Embodiments

It is to be understood that while the invention has been described in conjunction with the detailed description thereof, the foregoing description is intended to illustrate and not limit the scope of the invention, which is defined by the scope of the appended claims. Other aspects, advantages, and modifications are within the scope of the following claims. 

1. A method for assessing a human having a brain aneurysm, said method comprising: (a) detecting the presence of two or more polymorphisms in SEQ ID NO:1 in said human, wherein at least two of said two or more polymorphisms are selected from the group consisting of 27 VNTR, T-786C SNP, and G894T SNP, and wherein the presence of said two or more polymorphisms indicates that said brain aneurysm is prone to rupture, and (b) classifying said human as having a brain aneurysm that is prone to rupture.
 2. The method of claim 1, wherein said brain aneurysm is between 2 and 10 mm in diameter.
 3. The method of claim 1, wherein said brain aneurysm is present in a location selected from the group consisting of an anterior communicating artery, an anterior cerebral artery, a middle cerebral artery, an internal carotid artery, a posterior communicating artery, a posterior cerebral artery, a basilar artery, and a vertebral artery.
 4. The method of claim 1, wherein said human is heterozygous for said two or more polymorphisms.
 5. The method of claim 1, wherein said human is homozygous for said two or more polymorphisms.
 6. The method of claim 1, wherein said method comprises detecting three or more polymorphisms in SEQ ID NO:1 in said human.
 7. A method for determining to treat a brain aneurysm in a human, said method comprising: (a) detecting the presence of two or more polymorphisms in SEQ ID NO:1 in said human, wherein at least two of said two or more polymorphisms are selected from the group consisting of 27 VNTR, T-786C SNP, and G894T SNP, and wherein the presence of said two or more polymorphisms indicates that said brain aneurysm should be treated, and (b) classifying said human as having a brain aneurysm that should be treated.
 8. The method of claim 7, wherein said brain aneurysm is between 2 and 10 mm in diameter.
 9. The method of claim 7, wherein said brain aneurysm is present in a location selected from the group consisting of an anterior communicating artery, an anterior cerebral artery, a middle cerebral artery, an internal carotid artery, a posterior communicating artery, a posterior cerebral artery, a basilar artery, and a vertebral artery.
 10. The method of claim 7, wherein said human is heterozygous for said two or more polymorphisms.
 11. The method of claim 7, wherein said human is homozygous for said two or more polymorphisms.
 12. The method of claim 7, wherein method comprises detecting three or more polymorphisms in SEQ ID NO:1 in said human.
 13. The method of claim 7, wherein said method comprises determining the size of said brain aneurysm.
 14. The method of claim 7, wherein said method comprises determining the location of said brain aneurysm.
 15. A method for determining to treat a brain aneurysm in a human, said method comprising: (a) detecting the presence of two or more polymorphisms in SEQ ID NO:1 in said human, wherein at least two of said two or more polymorphisms are selected from the group consisting of 27 VNTR, T-786C SNP, and G894T SNP, (b) determining that the size of said brain aneurysm is between 2 and 10 mm in diameter or determining that the location of said brain aneurysm is in an anterior communicating artery or a posterior communicating artery of said human, wherein the presence of said two or more polymorphisms in said human and the presence of said size or said location indicates that said brain aneurysm should be treated, and (c) classifying said human as having a brain aneurysm that should be treated if said brain aneurysm comprises said size or said location.
 16. The method of claim 15, wherein said method comprises determining that said human is homozygous for said two or more polymorphisms.
 17. The method of claim 15, wherein said human is heterozygous for said two or more polymorphisms.
 18. The method of claim 15, wherein said human is homozygous for said two or more polymorphisms.
 19. The method of claim 15, wherein said method comprises detecting the presence of three or more polymorphisms in SEQ ID NO:1 in said human.
 20. The method of claim 15, said method comprises determining that the size of said brain aneurysm is between 2 and 10 mm in diameter and comprises determining that the location of said brain aneurysm is in an anterior communicating artery or a posterior communicating artery of said human, wherein the presence of said two or more polymorphisms in said human and the presence of said size and said location indicates that said brain aneurysm should be treated. 